Surgical resection of adenocarcinoma can significantly improve survival, but only 20% of patients are candidates to undergo this treatment. Typically, patients with unresectable pancreatic adenocarcinoma receive palliative, non-curative therapy. Recent research, however, suggests that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients who have been previously deemed unresectable the possibility for curative salvage pancreatectomy.
A New Approach for Pancreatic Cancer
In the Journal of the American College of Surgeons, my colleagues and I at MD Anderson reported results from a study cohort of 88 high-risk patients who had been informed that their tumors were inoperable after an initial surgical attempt at removal. Of these patients, 66 completed a multidisciplinary treatment protocol with successful tumor removal. Risk for metastatic disease was stratified based on tumor involvement with local blood vessels, biopsy results and the nature of the tumor, and overall health status aside from pancreatic cancer. Patients who met these criteria underwent the MD Anderson protocol, which involved the following:
A collaborative interpretation of pancreas-specific CT scans by surgeons and radiologists.
Carefully administered preoperative chemotherapy and radiation treatment with multidisciplinary restaging prior to surgery.
Use of advanced surgical techniques with planned removal and vascular reconstruction of involved blood vessels near the tumor.
Using this protocol, we achieved survival numbers that are comparable to those of patients receiving surgery for clearly operable tumors. On average, patients undergoing the MD Anderson protocol lived about 30 months after tumor removal, which is almost three times longer than the average survival of 11 months for patients who do not undergo tumor resection.
Key Considerations: Patient Selection & Imaging
Our findings are encouraging, but it should be noted that the protocol developed at MD Anderson is one that has been explored and refined at our institution over the last 20 years. Several considerations are important to note. Patient selection is critical and was likely reflected in this retrospective report. Radiographic imaging is the key component necessary for selection, and the interpretation of CT scans needs to be performed by both radiologists and surgeons. With good imaging and interpretation, surgeons can get a clear idea of tumor location and usually predict involvement of the vessels and the need for vascular resection and reconstruction.
Hospital type and surgeon skill are not necessarily indicators of the setting in which the MD Anderson protocol can be effective. The protocol can be utilized at other institutions, but requires a high level of technical surgical skill as well as a focused team of specialists. Although our study was a small series that involved high-risk patients, it’s one of the largest to include patients who had a previous unsuccessful attempt at tumor removal and provides a strong foundation for future analyses.
Readings & Resources (click to view)
Truty MJ, Thomas RM, Katz MH, et al. Multimodality therapy offers a chance for cure in patients with pancreatic adenocarcinoma deemed unresectable at first operative exploration. J Am Coll Surg. 2012;215:41-51. Available at: http://www.journalacs.org/article/S1072-7515(12)00319-5/abstract.
Katz MH, Pisters PW, Evans DB, et al. Borderline resectable pancreatic cancer: the importance of this emerging stage of disease. J Am Coll Surg. 2008;206:833-846; discussion 846-848.
Winter JM, Cameron JL, Campbell KA, et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg. 2006;10:1199-1210; discussion 1210-1211.
Tamm EP, Loyer EM, Faria S, et al. Staging of pancreatic cancer with multidetector CT in the setting of preoperative chemoradiation therapy. Abdom Imaging. 2006;31:568-574.
Varadhachary GR, Tamm EP, Abbruzzese JL, et al. Borderline resectable pancreatic cancer: definitions, management, and role of preoperative therapy. Ann Surg Oncol. 2006;13:1035-1046.
Katz MH, Wang H, Fleming JB, et al. Long-term survival after multidisciplinary management of resected pancreatic adenocarcinoma. Ann Surg Oncol. 2009;16:836-847.
Satoi S, Yanagimoto H, Toyokawa H, et al. Surgical results after preoperative chemoradiation therapy for patients with pancreatic cancer. Pancreas. 2009;38:282-288.